BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN (NATER RESOURCES CONTR$SOARD ; UNDERGROUND STORAGE TANK PROGRAM FORM 'B': TANK TANK PERMIT APPLICATION INFORMATION ro COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 NEW PERMIT ❑3 RENEWAL PERMIT E]5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK o MARK ONLY F-1 ❑ 6 TEMPORARY TANK CLOSURE �� ANK REMOVED 09 r)ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT FARM TANK-YES❑ NO 4b- FACILITY/SITE FACILITY/SITE NAME WHERE TANK IS INSTALLED: w I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY (� B. MANUFACTURED BY: A. OWNERS TANK ID# C. YEAR INSTALLED u,N.k_ D. TANK CAPACITY IN GALLONS: IL MF ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOIJACRKE❑D,COMER ED ��LEADED ❑ 3 DIESEL e. VEHICLE FUEL KER UM ��/PRODUCT ❑4 GASAHOL ❑5 JET FUEL k ❑-6 AVIATION GASAL PRODUCT iL�J 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW)DOUS ❑95 UNKNOWN ❑ 2 WASTE ❑ ❑R VEHICLE FUEOF C.A.S.W SUBSTANCE S # III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D ❑3 SINGLE WAILED WITH E%1ERIORUNER ❑95 UNKNOWN A.TYPE OF ❑ 1 DOUBLE WALLED g9 OTHER - SYSTEM � SINGUE WALLED El SECONDARY CONTAINMENT ❑ � �, STEELIIRON ❑2 STAINLESS STEEL ❑ 3FIBERGLASS ❑4 STEEL CIAO WIRBERGLASS REINFORCED PLASTIC Y__J CONCRETE B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM.. ❑6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNUNED 'E�H5 UNKNOWN LINING ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES F] NO 99 OTHER D.CORROSION ❑ 1 PoLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYLWAAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 5 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,ATBOTNIF'APPI.IC9 BNONE A U 5 UNKNOWN A u 99 OTLE HER A,SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U INED TRENCH A U 91 NONE A U 95 NKNOWN A U 99 OTHER A U 1 STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A u 811080%FIBERGLASS ANOL COMPAPIPE A TIBLE TR91 IP C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FflP A U 9 GALVANIZED STEEL A KNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. p S 1 VISUAL CHECK P S 21NVENTORY RECONCILIATION P a 91VNONEE WELLS P S 4EUNKNOOWN NICMONITOR P s 99GOTTHERD WATER MONITORING WELLS p 5 6 PRECISION TESTING P 5 7 PRESSURE TESTING VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES E] NO 1.ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNODWTE DGE,IS TRUE AND CORRECT. APPLICANT'SNAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY TANK ID# COUNTY# JURISDICTION# AGE FACILITY ID# CURRENT LOC AGENCYApp pOVED gy NAME � � PHONE�N WITH AREA ACOIL1 FACILITY �`) � , Q-0 PERMIT APPROVAL DATE/XIPERMIT EXPIRATION DATE PERMIT NUMBER CNECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTM BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE.a A FACILITYDATAPPROCION, FORM 'A',UNLESS RENT FORMA' HAS BEEN FILED